We’re here to create a customized program based on your unique values, experiences and habits. In order for you to gain the most benefit from this program, we encourage you to answer all the following questions. If you are uncomfortable with answering a particular question, feel free to leave it blank. Remember! This is a judgement-free zone. We are here to help!

Name *
Date of Birth
Date of Birth
Please note: We will need you to explain all YES answers for the questions below in the final open text box at the end of this questionnaire. Please make note of which questions you will need to return.
Have you ever had any of the following conditions?
1. Allergies
2. Loss of hearing
3. Asthma
4. Kidney Diease
5. Prostatitis
6. Colitis
7. Hepatitis
8. Liver Disease
9. Elevated Liver Enzyme Test
10. Pancreatitis
11. Ulcer
12. Heart Attack
13. Heart Murmur
14. Positive Stress Test
15. Heart Valve Abnormality
16. Angina
17. Heart Failure
18. High Cholesterol
19. High Blood Pressure
20. Arthritis/Rheumatism
21. Loss of Consciousness
22. Epilepsy
23. Convulsions/Seizures
24. Stroke
25. Diabetes
26. Thyroid Trouble
27. Anemia
28. Eczema
29. Cancer (including skin cancer)
30. Sleep apnea
Do you currently have, or have you recently had any of the following?
Eyes, ears, Nose, Throat Symptoms
31. Difficulty with night vision
32. Change in vision
33. Blurred or double vision
34. Bleeding gums
35. Frequent nose bleeds
36. Frequent sinus trouble
37. Recent hoarseness
38. Ringing/buzzing ears
39. Earaches
Pulmonary Symptoms
40. Shortness of breath
41. Chronic or frequent cough
42. Brown/blood tinged sputum
43. Chest tightness
44. Wheezing
Genito-urinary symptoms
45. Bladder trouble
46. Blood in urine
47. Irregular vaginal bleeding
48. Currently pregnant
49. Difficulty starting/stopping urination
50. Urinating 3 times per night
51. Frequent or painful urination
52. Problems with sexual function
Gastrointestinal sytmptoms
53. Vomited blood
54. Persistent diarrhea
55. Persistent constipation
56. Frequent abdominal pain
57. Frequent nasea
58. Frequent indigestion/heartburn
59. Black/bloody bowel movement
60. Hemorrhoids
61. Trouble swallowing
62. Hernia
Central Nervous System Symptoms
63. Fainting spells
64. Recurrent dizziness
65. Frequent headaches
67. Memory loss
68. Loss of coordination
69. Difficulty concentrating
70. Numbness/tingling extremities
Heart/Vascular symptoms
71. Palpitation (irregular heartbeat)
72. Pain or discomfort in chest
73. High cholesterol
74. Swelling of feet
75. Leg pain while walking
76. Painful varicose veins
77. Back trouble/pain
78. Neck trouble/pain
79. Joint injury/pain/swelling
80. Carpal tunnel syndrome
Miscellaneous symptoms
81. Bleeding/bruising easily
82. Enlarged glands
83. Rashes
84. Unexplained lumps
85. Chronic fatigue
86. Night sweats
87. Undesired weight loss
88. Snoring
89. Difficulty sleeping
90. Low blood sugar
Additional Health & Lifestyle Questions
Please answer the following questions honestly.
91. Are you experiencing any stresses, mood patterns, relationship difficulties, or substance related problems for which you would like resource or referral information on a confidential basis?
92. Do you occasionally use or are you currently taking any prescription or over-the-counter medications?
Please list name, dosage, and the reason for the medication in the final box.
93. Have you had any surgical operations in the last 10 years?
94. Has anyone in your family developed heart disease before the age of 60?
If yes, please list relationship in the final text box.
95. Do any diseases run in the family?
96. Do you currently have a cold/cough, or have you had any in the last 2 weeks?
97. Have you ever been hospitalized?
If yes, please list the date, length of stay and reason in the final text box.
98. Are you currently under a doctor's care?
If yes, please list the reason in the final text block.
99. Have you had a change in the size or color of a mole, or a sore that would not heal in the past year?
100. Do you have any special concerns regarding your health that you would like to discuss with a doctor?
101. Are you currently a cigarette smoker?
102. Are you an ex-smoker?
103. Have you used chewing tobacco or smoked cigars/pipe in the last 15 years?